Provider Demographics
NPI:1366866469
Name:JACKSON, JENNIFER (LCSW-A/LCAS-A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW-A/LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 GARNER RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-4687
Mailing Address - Country:US
Mailing Address - Phone:919-832-7351
Mailing Address - Fax:919-571-2932
Practice Address - Street 1:2101 GARNER RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-4687
Practice Address - Country:US
Practice Address - Phone:919-832-7351
Practice Address - Fax:919-571-2932
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3468-A101YA0400X
NCP008214101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)